Fillable Statement-of-Financial-Support Statement of Financial Support

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Statement-of-Financial-Support Statement of Financial Support

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Country of origin: US
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_______________________________________________________ ___________________
______________________________________________________ ___________________
2018-2019
Statement of Financial Support
Student ID ___________________________________
____________________________________________ ________________________________________
Last Name First Name
The US Department of Education is requiring that you document how your family was financially supported in 2016. Students are required
to report any cash support that they or their parents received. Cash support includes money, gifts, loans, housing, food, clothing, car
payments or expenses, medical and dental care, and any money paid to someone else on their behalf. The US Department of Education
requires that we verify this information before disbursing federal funds.
Description of Expense
Monthly Expense Amount for 2016
Rent or Mortgage
$
Property Taxes and Insurance on Residence
$
Utilities and Telephone
$
Food
$
Clothing
$
Laundry and Cleaning
$
Un-Reimbursed Medical and Dental Expenses
$
Child Care
$
Car Payment
$
Car Insurance
$
Gasoline or other Transportation Costs
$
Child Support/Alimony paid by you or parent
$
Other Personal Expenses (specify):
$
Total Monthly Expenses
$
Please list all the MONTHLY resources that you and/or your Parent(s) used to meet the expenses listed above. Be sure
to include all wages, TANF, child support received, unemployment benefits, social security benefits, SSI, disability,
workers compensation, and/or any cash received.
Resources/Person(s) who helped Support Family
Monthly Amount Received for 2016
1.
$
2.
$
3.
$
4.
$
_____Yes _____No
_____Yes_____No
_____Yes _____No
Did you or your Parent(s) receive SNAP benefits in 2016?
Did you or your Parent(s) receive TANF benefits in 2016?
Did any in your household participate in the free lunch program?
Did you or your Parent(s) receive Subsidized Housing Benefits in 2016?
_____Yes _____No
Certification: I hereby certify that all the information reported on this form is true, complete, and accurate. Further, I understand that false statements and/or
misrepresentations will result in denial, reduction, withdrawal, and/or repayment of aid disbursed and student disciplinary action may be taken.
Student Signature Date
Spouse or Parent Signature Date
1570 East Colorado Blvd.L-114, Pasadena, California 91106
--
2003
19SFS
0
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Statement-of-Financial-Support Statement of Financial Support

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Completed 15 November 2019

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